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Foo20151013 2023 zwf33b?1444774244
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"So are you enjoying it?"

"When did the pain start Mr Smith?" "Ah so do you enjoy it?" 'It' of course refers to your five year medical degree. Patients can be nice can't they. Often it seems that all patients want to talk about is you. I thought the public didn't like students, aren't students lazy drunks who wake up at midday, squander their government hand-outs on designer clothes, and whose prevailing role in society was to keep the nation's budget baked bean industry in the black? Apparently the same isn't thought of medical students, well maybe it is, but god patients are polite. The thing is I have found these questions difficult; it is surprising how they can catch you off guard. Asking if I am enjoying 'it' after I have woken up at dawn, sat on a bus for 40 minutes, and hunted down a clinician who had no idea I was meant to be there, could lead on to a very awkward consultation. But of course it doesn't "yes it is really good thank you". "Do you take any medications, either from your GP or over the counter?" "Are you training to be a GP then?" Medicine is a fascinating topic and indeed career, which surely human nature makes us all interested in. As individuals lucky enough to be studying it, maybe we forget how intriguing the medical profession is? This paired with patients sat in a small formal environment with someone they don’t know could bring out the polite ‘Michael Parkinson’ in anybody. Isn't this just good manners, taking an interest. Well yes. Just because I can be faintly aloof doesn't mean the rest of the world has to me. But perhaps there is a little more to it, we ask difficult personal questions, sometimes without even knowing it, we all know when taking a sexual history to expect the consultation to be awkward or embarrassing, but people can be apprehensive talking about anything, be it their cardiovascular disease, medications, even their date of birth. We often then go on to an examination: inspecting from the end of the bed, exposing a patient, palpating. Given a bit context you can see why a patient may want to shift the attention back to someone like us for a bit, and come on, the medical student is fair game, the best target, asking the consultant whether they enjoys their job, rather you than me. If we can oblige, and make a patient feel a bit more at ease we should, and it certainly won't be doing our student patient relationship any harm. Hopefully next time my answers will be a bit more forthcoming. "Any change in your bowels, blood in any motions?" "How many years do you have left?" It is a good thing we are all polite.  
Joe de Silva
over 5 years ago
Foo20151013 2023 vvr5q9?1444774253
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184

Clinics - Making the most of it

Commencing the first clinical year is a milestone. Things will now be different as your student career steers straight into the unchartered waters of clinical medicine. New challenges and responsibilities lie ahead and not just in an academic sense. After all this is the awaited moment, the start of the apprenticeship you have so desired and laboured for. It won’t be long before these clinical years like the preclinical years before them, will seem just as distant and insular, so why not make the most of it? The first days hold so much excitation and promise and for many they deliver, however, it would be wise not to be too optimistic. I am afraid your firm head standing abreast the doors in a prophetic splaying of arms is an unlikely sight. In this new clinical environment, it is natural to be a little flummoxed. The quizzical looks of doctors and nurses as you first walk in, a sure sign of your unexpected arrival, is a recurring theme. If the wards are going to be your new hunting ground, proper introductions with the medical team are in order. This might seem like a task of Herculean proportions, particularly in large teaching hospitals. Everyone is busy. Junior doctors scuttling around the ward desks job lists in hand, the registrar probably won’t have noticed you and as luck would have it your consultant firm head is away at a conference. Perseverance during these periods of frustration is a rewarding quality. Winning over the junior doctors with some keenness will help you no end. What I mean to say is that their role in our learning as students extends further than the security of sign-off signatures a week before the end of the rotation. They will give you opportunities. Take them! Although it never feels like it at the time, being a medical student does afford some privileges. The student badge clipped to your new clinic clothes is a license to learn: to embark on undying streaks of false answers, to fail as many skills and clerkings as is required and to do so unabashed. Unfortunately, the junior doctors are not there purely for your benefit, they cannot always spare the time to directly observe a history taking or an examination, instead you must report back. With practice this becomes more of a tick box exercise: gleaning as much information and then reconfiguring it into a structured presentation. However, the performance goes unseen and unheard. I do not need to iterate the inherent dangers of this practice. Possible solutions? Well receiving immediate feedback is more obtainable on GP visits or at outpatient clinics. They provide many opportunities to test your questioning style and bedside manner. Performing under scrutiny recreates OSCE conditions. Due to time pressure and no doubt the diagnostic cogs running overtime, it is fatefully easy to miss emotional cues or derail a conversation in a way which would be deemed insensitive. Often it occurs subconsciously so take full advantage of a GP or a fellow firm mate’s presence when taking a history. Self-directed learning will take on new meaning. The expanse of clinical knowledge has a vertiginous effect. No longer is there a structured timetable of lectures as a guide; for the most part you are alone. Teaching will become a valued commodity, so no matter how sincere the promises, do not rest until the calendars are out and a mutually agreed time is settled. I would not encourage ambuscaded attacks on staff but taking the initiative to arrange dedicated tutorial time with your superiors is best started early. Consigning oneself to the library and ploughing through books might appear the obvious remedy, it has proven effective for the last 2-3 years after all. But unfortunately it can not all be learnt with bookwork. Whether it is taking a psychiatric history, venipuncture or reading a chest X-ray, these are perishable skills and only repeated and refined practice will make them become second nature. Balancing studying with time on the wards is a challenge. Unsurprisingly, after a day spent on your feet, there is wavering incentive to merely open a book. Keeping it varied will prevent staleness taking hold. Attending a different clinic, brushing up on some pathology at a post-mortem or group study sessions adds flavour to the daily routine. During the heated weeks before OSCEs, group study becomes very attractive. While it does cement clinical skills, do not be fooled. Your colleagues tend not to share the same examination findings you would encounter on an oncology ward nor the measured responses of professional patient actors. So ward time is important but little exposure to all this clinical information will be gained by assuming a watchful presence. Attending every ward round, while a laudable achievement, will not secure the knowledge. Senior members of the team operate on another plane. It is a dazzling display of speed whenever a monster list of patients comes gushing out the printer. Before you have even registered each patient’s problem(s), the management plan has been dictated and written down. There is little else to do but feed off scraps of information drawn from the junior doctors on the journey to the next bed. Of course there will be lulls, when the pace falls off and there is ample time to digest a history. Although it is comforting to have the medical notes to check your findings once the round is over, it does diminish any element of mystery. The moment a patient enters the hospital is the best time to cross paths. At this point all the work is before the medical team, your initial guesses might be as good as anyone else’s. Visiting A&E of your own accord or as part of your medical team’s on call rota is well worth the effort. Being handed the initial A&E clerking and gingerly drawing back the curtain incur a chilling sense of responsibility. Embrace it, it will solidify not only clerking skills but also put into practice the explaining of investigations or results as well as treatment options. If you are feeling keen you could present to the consultant on post-take. Experiences like this become etched in your memory because of their proactive approach. You begin to remember conditions associated with patient cases you have seen before rather than their corresponding pages in the Oxford handbook. And there is something about the small thank you by the F1 or perhaps finding your name alongside theirs on the new patient list the following morning, which rekindles your enthusiasm. To be considered part of the medical team is the ideal position and a comforting thought. Good luck. This blog post is a reproduction of an article published in the Medical Student Newspaper, Freshers 2013 issue.  
James Wong
over 5 years ago
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A Modest Man

The registrar's face was taking on a testy look. So enduring was the silence our furtive glances had developed a nystagmic quality. “Galactosaemia” came her peremptory reply. Right on queue the disjointed chorus of ahs and head nods did little to hide our mental whiteboard of differentials being wiped clean. At the time conjugated bilirubinaemia in children only meant one thing: biliary atresia. A fair assumption; we were sitting in one of three specialist centres in the country equipped to treat these patients. Ironically the condition has become the unwieldy yardstick I now measure the incidence of paediatric disease. Biliary atresia is the most common surgical cause of neonatal jaundice with a reported incidence of 1 in 14-16ooo live births in the West. It is described as a progressive inflammatory obliteration of the extrahapatic bile duct. And Dr Charles West, the founder of Great Ormond Street Hospital, offers an eloquent description of the presenting triad of prolonged jaundice, pale acholic stools and dark yellow urine: ‘Case 18...It was born at full term, though small, apparently healthy. At 3 days however, it began to get yellow and at the end of 3 weeks was very yellow. Her motions at no time after the second day appeared natural on examination, but were white, like cream, and her urine was very high coloured.’ 1855 was the year of Dr West's hospital note. An almost universally fatal diagnosis and it would remain so for the next 100 years. The time's primordial classification of biliary atresia afforded children with the 'noncorrectable' type, a complete absence of patent extrahepatic bile duct, an unfortunate label; they were beyond saving. Having discovered the extent of disease at laparatomy, the surgeons would normally close the wound. The venerable Harvardian surgeon, Robert E. Gross saved an enigmatic observation: “In most instances death followed a downhill course…” K-A-S-A-I read the ward’s board. It was scrawled under half the children's names. I dismissed it as just another devilishly hard acronym to forget. The thought of an eponymous procedure had escaped me and in biliary atresia circles, it's the name everyone should know: Dr Morio Kasai. Originating from Aomori prefecture, Honshu, Japan, Dr Kasai graduated from the National Tohoku University School of Medicine in 1947. His ascension was rapid, having joined the 2nd department of Surgery as a general surgeon, he would assume the role of Assistant Professor in 1953. The department, under the tenure of Professor Shigetsugu Katsura, shared a healthy interest in research. 1955 was the landmark year. Katsura and Kasai operated on their first case: a 72 day old infant. Due to bleeding at the incised porta hepatis, Katsura is said to have 'placed' the duodenum over the site in order to staunch the flow. She made a spectacular postoperative recovery, the jaundice had faded and there was bile pigment in her stool. During the second case, Katsura elected to join the unopened duodenum to the porta hepatis. Sadly the patient's jaundice did not recover, but the post-mortem conducted by Kasai confirmed the development of a spontaneous internal biliary fistula connecting the internal hepatic ducts to the duodenum. Histological inspection of removed extrahepatic duct showed the existence of microscopic biliary channels, hundreds of microns in diameter. Kasai made a pivotal assertion: the transection of the fibrous cord of the obliterated duct must contain these channels before anastomosis with the jejunal limb Roux-en-Y loop. This would ensure communication between the porta hepatis and the intrahepatic biliary system. The operation, entitled hepatic portoenterostomy, was first performed as a planned procedure for the third case at Tohoku. Bile flow was restored and Kasai published the details of the new technique in the Japanese journal Shujutsu in 1959. However, news of this development did not dawn on the West until 1968 in the Journal of Pediatric Surgery. The success of the operation and its refined iterations were eventually recognized and adopted in the 1970s. The operation was and is not without its dangers. Cholangitis, portal hypertension, malnutrition and hepatopulmonary syndrome are the cardinal complications. While diagnosing and operating early (<8 weeks) are essential to the outcome, antibiotic prophylaxis and nutritional support are invaluable prognostic factors. Post operatively, the early clearance of jaundice (within 3 months) and absence of liver cirrhosis on biopsy, are promising signs. At UK centres the survival after a successful procedure is 80%. The concurrent development of liver transplantation boosts this percentage to 90%. Among children, biliary atresia is the commonest indication for transplantation; by five years post-Kasai, 45% will have undergone the procedure. On the 6th December 2008, Dr Kasai passed away. He was 86 years old and had been battling the complications of a stroke he suffered in 1999. His contemporaries and disciples paint a humble and colourful character. A keen skier and mountaineer, Dr Kasai lead the Tohoku University mountain-climbing team to the top of the Nyainquntanglha Mountains, the highest peaks of the Tibetan highlands. It was the first successful expedition of its kind in the world. He carried through this pioneering spirit into his professional life. Paediatric surgery was not a recognized specialty in Japan. By founding and chairing multiple associations including the Japanese Society of Pediatric Surgeons, Dr Kasai gave his specialty and biliary atresia, the attention it deserved. Despite numerous accolades of international acclaim for his contributions to paediatric surgery, Dr Kasai insisted his department refer to his operation as the hepatic portoenterostomy; the rest of the world paid its originator the respect of calling it the ‘Kasia’. Upon completion of their training, he would give each of his surgeons a hand-written form of the word ‘Soshin’ [simple mind], as he believed a modest surgeon was a good one. At 5 foot 2, Kasai cut a more diminutive figure one might expect for an Emeritus Professor and Hospital Director of a university hospital. During the course of his lifetime he had developed the procedure and lived to see its fruition. The Kasia remains the gold standard treatment for biliary atresia; it has been the shinning light for what Willis J. Potts called the darkest chapter in paediatric surgery. It earned Dr Kasai an affectionate but apt name among his peers, the small giant. References Miyano T. Morio Kasai, MD, 1922–2008. Pediatr Surg Int. 2009;25(4):307–308. Garcia A V, Cowles RA, Kato T, Hardy MA. Morio Kasai: a remarkable impact beyond the Kasai procedure. J Pediatr Surg. 2012;47(5):1023–1027. Mowat AP. Biliary atresia into the 21st century: A historical perspective. Hepatology. 1996;23(6):1693–1695. Ohi R. A history of the Kasai operation: Hepatic portoenterostomy for biliary atresia. World J Surg. 1988;12(6):871–874. Ohi R. Morio Kasai, MD 1922-2008. J Pediatr Surg. 2009;44(3):481–482. Lewis N, Millar A. Biliary atresia. Surg. 2007;25(7):291–294. This blog post is a reproduction of an article published in the Medical Student Newspaper, April 2014 issue.  
James Wong
over 5 years ago
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Confidence Building During Medical Training

My fellow medical students, interns, residents and attendings: I am not a medical student but an emeritus professor of Obstetrics and Gynecology at the University of Miami Miller School of Medicine, and also a voluntary faculty member at the Florida International University Herbert Wertheim College of Medicine. I have a great deal of contact with medical students and residents. During training (as student or resident), gaining confidence in one's own abilities is a very important part of becoming a practitioner. This aspect of training does not always receive the necessary attention and emphasis. Below I describe one of the events of confidence building that has had an important and lasting influence on my career as an academic physician. I graduated from medical school in Belgium many years ago. I came to the US to do my internship in a small hospital in up state NY. I was as green as any intern could be, as medical school in Belgium at that time had very little hands on practice, as opposed to the US medical graduates. I had a lot of "book knowledge" but very little practical confidence in myself. The US graduates were way ahead of me. My fellow interns, residents and attendings were really understanding and did their best to build my confidence and never made me feel inferior. One such confidence-building episodes I remember vividly. Sometime in the middle part of the one-year internship, I was on call in the emergency room and was called to see a woman who was obviously in active labor. She was in her thirties and had already delivered several babies before. The problem was that she had had no prenatal care at all and there was no record of her in the hospital. I began by asking her some standard questions, like when her last menstrual period had been and when she thought her due date was. I did not get far with my questioning as she had one contraction after another and she was not interested in answering. Soon the bag of waters broke and she said that she had to push. The only obvious action for me at that point was to get ready for a delivery in the emergency room. There was no time to transport the woman to the labor and delivery room. There was an emergency delivery “pack” in the ER, which the nurses opened for me while I quickly washed my hands and put on gloves. Soon after, a healthy, screaming, but rather small baby was delivered and handed to the pediatric resident who had been called. At that point it became obvious that there was one more baby inside the uterus. Realizing that I was dealing with a twin pregnancy, I panicked, as in my limited experience during my obstetrical rotation some months earlier I had never performed or even seen a twin delivery. I asked the nurses to summon the chief resident, who promptly arrived to my great relief. I immediately started peeling off my gloves to make room for the resident to take my place and deliver this twin baby. However, after verifying that this baby was also a "vertex" without any obvious problem, he calmly stood by, and over my objections, bluntly told me “you can do it”, even though I kept telling him that this was a first for me. I delivered this healthy, screaming twin baby in front of a large number of nurses and doctors crowding the room, only to realize that this was not the end of it and that indeed there was a third baby. Now I was really ready to step aside and let the chief resident take over. However he remained calm and again, stood by and assured me that I could handle this situation. I am not even sure how many triplets he had delivered himself as they are not too common. Baby number three appeared quickly and also was healthy and vigorous. What a boost to my self-confidence that was! I only delivered one other set of triplets later in my career and that was by C-Section. All three babies came head first. If one of them had been a breech the situation might have been quite different. What I will never forget is the implied lesson in confidence building the chief resident gave me. I have always remembered that. In fact I have put this approach in practice numerous times when the roles were reversed later in my career as teacher. Often in a somewhat difficult situation at the bedside or in the operating room, a student or more junior doctor would refer to me to take over and finish a procedure he or she did not feel qualified to do. Many times I would reassure and encourage that person to continue while I talked him or her through it. Many of these junior doctors have told me afterwards how they appreciated this confidence building. Of course one has to be careful to balance this approach with patient safety and I have never delegated responsibility in critical situations and have often taken over when a junior doctor was having trouble. Those interested, can read more about my experiences in the US and a number of other countries, in a free e book, entitled "Crosscultural Doctoring. On and Off the Beaten Path" can be downloaded at this link. Enjoy!  
DR William LeMaire
over 5 years ago
Foo20151013 2023 1n8q51t?1444774287
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132

Email Gone Astray

An email gone astray can provide fascinating insights for an unintended recipient. Written correspondence has undoubtedly fallen into the wrong hands since homo sapiens first put pigment on bark, but never before has it been so easy to have a personal message go awry. No longer is it a matter of surreptitiously steaming open sealed letters or snooping around in wastepaper baskets. Finding out another's personal business is now just a click away. Even more conveniently, candid opinions can sometimes make an unscheduled landing in your inbox, making for intriguing reading -- as I discovered. Some time ago, I'd sent out feelers regarding possible new GP jobs and had emailed a particular practice principal a couple of times, expressing interest. When it looked likely that I was going to pursue a different path, I sent a polite email explaining the situation and telling him I wouldn't be seeking an interview for a job at his practice at present. An email bounced back saying that my not wanting to work for him may be "a relief" as I "sounded a bit intense". It was sans salutation but, based on the rest of the content, was obviously intended for one of his work colleagues. It had no doubt been a simple error of his pressing 'reply' rather than 'forward'. I was chuffed: I've never been called "intense" before, at least, not to my knowledge. Perhaps there are several references to my intensity bouncing around cyberspace but this is the only one my inbox has ever captured. I've never considered myself an intense person. To me, the term conjured up the image of a passionate yet very serious type, often committed to worthy causes. Perhaps I had the definition wrong. I looked it up. The Oxford Dictionary gave me: "having or showing strong feelings or opinions; extremely earnest or serious". Unfortunately, I couldn't reconcile my almost pathologically Pollyanna-ish outlook, enthusiasm, irreverence and light-heartedness to this description -- nor my somewhat ambivalent approach to politics, religion, sport, the environment and other "serious" issues. At least the slip-up was minor. Several years ago, I unintentionally managed to proposition one of my young, shy GP registrars by way of a wayward text message. He had the same first name as my then-husband. Scrolling through my phone contacts late one night, alone in a hotel room at an interstate medical conference, I pressed one button too many. Hence this innocent fellow received not only declarations of love but a risqué suggestion to go with it. Not the usual information imparted from medical educator to registrar! It took me several days to realise my error, but despite my profuse apologies, the poor guy couldn't look me in the eye for the rest of the term. If I was "intense", I would conclude on a ponderous note -- with a moral message that would resonate with the intellectually elite. Alas, I'm a far less serious kind of girl and, as a result, the best I can up with is: Senders of emails and texts beware -- you are but one click away from being bitten on the bottom. (This blog post has been adapted from a column first published in Australian Doctor). Dr Genevieve Yates is an Australian GP, medical educator, medico-legal presenter and writer. You can read more of her work here.  
Dr Genevieve Yates
over 5 years ago
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Someone to hold your hand

Having a companion can get a stroke victim faster treatment  
economist.com
over 4 years ago
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Global Hands - Social Determinants of Health

http://armandoh.org/ Facebook: Global Hands (Global Health at Notre Dame Sydney) Twitter: @GlobalHealthNDS Instagram: @GlobalHands http://mandus.org.au/globa...  
youtube.com
over 4 years ago
Www.bmj
0
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A sinister cause of shoulder pain, with numbness and weakness in the ipsilateral hand

A 41 year old patient with insulin dependent diabetes presented with a one month history of progressively worsening pain, numbness, and weakness of his right shoulder and arm. His history included peripheral vascular disease, chronic renal failure, and chronic pancreatitis. He was also a smoker with a 60 pack year history.  
feeds.bmj.com
over 4 years ago
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3
234

Upper Limb Arteries - Hand and Wrist - 3D Anatomy Tutorial

Blood supply to the hand and wrist upper limb arteries anatomy tutorial. Check out the 3D app at http://AnatomyLearning.com. More tutorials available on http...  
youtube.com
over 4 years ago
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0
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Upper Limb Arteries - Hand and Wrist - 3D Anatomy Tutorial - YouTube

Blood supply to the hand and wrist upper limb arteries anatomy tutorial. More tutorials available on http://AnatomyZone.com. The following structures are rev...  
youtube.com
over 4 years ago
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0
0

Is painful knee and hand osteoarthritis in women associated with excess mortality?

Study compares mortality rates of women with painful knee and hand osteoarthritis with the mortality of unaffected women from the same community; demonstrates higher risk of early death in...  
medicalnewstoday.com
over 4 years ago
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0
2

Chemical and biological warfare agents neutralized by microrockets fueled by water

With fears growing over chemical and biological weapons falling into the wrong hands, scientists are developing microrockets to fight back against these dangerous agents, should the need arise.  
medicalnewstoday.com
over 4 years ago
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0
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How cells defend themselves against antibiotics and cytostatic agents

'On the one hand, ABC transporters cause diseases such as cystic fibrosis, while on the other hand they are responsible for the immune system recognising infected cells or cancer cells,'...  
medicalnewstoday.com
over 4 years ago
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0
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Finger lengths may indicate risk of schizophrenia in males

Research suggests that the ratio of the lengths of the index finger and the ring finger in males may be predictive of a variety of disorders related to disturbed hormonal balance.  
medicalnewstoday.com
over 4 years ago
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0
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Potential for a faster, simpler diagnosis for fibromyalgia using a finger-stick blood sample

Researchers have developed a reliable way to use a finger-stick blood sample to detect fibromyalgia syndrome, a complicated pain disorder that often is difficult to diagnose.  
medicalnewstoday.com
over 4 years ago
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0
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New research sheds light on how popular probiotic benefits the gut

Study suggests the bacteria may work by lending a hand to other microbesIn recent years, research into the benefits of gut bacteria has exploded.  
medicalnewstoday.com
over 4 years ago
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0
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Preliminary results further confirms the effectiveness of electroCore's non-invasive vagus nerve stimulation treatment for headache

Preliminary results of an open-label trial carried in the journal of Headache and Pain reported that a single treatment with electroCore's hand held non-invasive vagus nerve stimulation...  
medicalnewstoday.com
over 4 years ago
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Prosthetic hands, robotic trousers and biosensors - £5.3 million for healthcare tech research

A prosthetic hand controlled by the nervous system, robotic clothing to help people with walking, and biosensors to monitor how patients use equipment or exercise during rehabilitation are the...  
medicalnewstoday.com
over 4 years ago
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Tests reveal under-reported exposure to tobacco smoke among preemies with lung disease

Findings suggest high levels of false caregiver smoking reports or second-hand exposure in multi-unit housingPublic health experts have long known that tobacco smoke...  
medicalnewstoday.com
over 4 years ago
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University of Houston researchers build brain-machine interface to control prosthetic hand

Non-invasive technique allows amputee to use bionic hand, powered by his...  
medicalnewstoday.com
over 4 years ago